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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 2  |  Issue : 1  |  Page : 15-17

Tetanus and its continuing menace in the developing world: Critical care management


Department of Anesthesiology and Intensive Care, Dr. Ram Manohar Lohia Hospital, Postgraduate Institute of Medical Education and Research, Central Health Services, New Delhi, India

Date of Web Publication10-Oct-2018

Correspondence Address:
Uma Hariharan
Fellowship Oncoanaesthesia, CCEPC, DNB, FICA, Advanced Regional Anesthesia, BH 41, East Shalimar Bagh, New Delhi - 110 088
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sccj.sccj_4_18

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  Abstract 


Tetanus, also known as lockjaw, is an infection characterized by muscle spasms. In the most common type, the spasms begin in the jaw and then progress to the rest of the body. These spasms usually last a few minutes each time and occur frequently for three to four weeks. Tetanus is a disease caused by the toxin produced by the ubiquitous bacterium, Clostridium tetani. C tetani infection can be acquired through surgery, intravenous drug abuse, the neonate's umbilicus, bites, burns, body piercing, puncture wounds, and ear infections. This organism can enter through any break in the integrity of the body. We hereby describe the successful management, including critical care challenges of a case of Tetanus in a young male patient following a minor toe injury. Timely airway management followed by early tracheostomy with effective control of muscle spasms and other supportive therapy is highlighted. Tetanus continues to be a menacing infectious disease with high fatality in the developing world.

Keywords: Clostridium tetani, critical care, spasms, tetanus, tracheostomy, ventilator


How to cite this article:
Hariharan U, Sonowal S, Kaur R, Chaudhary L. Tetanus and its continuing menace in the developing world: Critical care management. Saudi Crit Care J 2018;2:15-7

How to cite this URL:
Hariharan U, Sonowal S, Kaur R, Chaudhary L. Tetanus and its continuing menace in the developing world: Critical care management. Saudi Crit Care J [serial online] 2018 [cited 2018 Dec 10];2:15-7. Available from: http://www.sccj-sa.org/text.asp?2018/2/1/15/243016




  Introduction Top


Tetanus is a deadly infection caused by the Gram-positive bacillus Clostridium tetani.[1] It is an obligate anaerobe, whose spores are highly resistant to extremes of temperature and disinfection. They are present all over the world in fecal matter (both humans and animals), soil and manure. Farmers, field workers, children, and people affected by natural disasters are prone to developing this infection following minor injuries.[2] The bacterial spores enter the body through contaminated superficial and deep wounds, flourishing in anaerobic environments (devitalized or necrotic tissue, with low oxygen content). Tetanus is an exotoxin-mediated disease, with the organism producing two exotoxins: hemolysin and tetanospasmin.[3] Tetanospasmin is a neurotoxin which enters and binds to the gangliosides of the central nervous system, causing the clinical manifestations of the disease. We hereby describe the medical and critical care management of a case of severe tetanus in a young male patient following a minor toe injury in the fields.


  Case Report Top


A young, ASA-Grade 1, male got injured in his great toe of the right foot during routine work in his farming fields. When the injury did not heal in 2 days, he went to a local doctor for dressing. Five days after the injury, he developed pain and stiffness in the face, with difficulty in opening his mouth. He initially consulted his community hospital, which referred the patient to our tertiary care center.

On presentation to our hospital, the patient was conscious, oriented, and afebrile, with stable vital parameters. On the foot examination, there was a wound with diameter 2 cm × 2 cm in his right foot with pus secretion. There was spasm of his jaw muscles with difficulty in opening the mouth fully. On detailed examination, there was spasm of his lower back muscles on stimulation. Other systemic examinations were unremarkable. All routine laboratory investigations were ordered, whose results are as follows: white blood cell = 12,000/μL (P = 65%, L = 35%); hemoglobin (HB) = 13 g/dL; platelet count = 2,10,000/μL; alanine transaminase = 23 IU/L; aspartate transaminase = 26 IU/L; alkaline phosphatase = 150; erythrocyte sedimentation rate = 30 mm/h; C-reactive protein = 9 mg/dl; urea = 34 mg/dl; creatinine = 0.8 mg/dl; calcium = 8.9 mg/dL; sodium = 139 mEq/L; and viral markers (HIV, hepatitis B surface antigen, hepatitis C virus) = Negative.

A provisional diagnosis of tetanus was made, and the patient was shifted to the Intensive Care Unit (ICU) on the next day when he started developing slight respiratory distress. Tetanus immune globulin (TIG) 500 international units (IU) and one dose of tetanus and diphtheria vaccine were administered. Antibiotics for secondary bacterial infection and injection metronidazole (500 mg intravenous, 6 hourly) for anaerobic cover were started, in addition to local wound debridement and dressing care. Diffuse, intermittent spasms of various parts of the body started to develop for which intravenous diazepam boluses (5 mg) were administered. With increasing muscle spasms, the patient was started on continuous intravenous midazolam hydrochloride infusion (titrated between 2 and 4 mg/h). With progressive respiratory embarrassment, the patient was intubated on the 4th day of admission with an 8.5 mm cuffed, polyvinyl chloride oral endotracheal tube. In addition to midazolam infusion, intravenous thiopentone infusions were started (titrated between 80 and 100 mg/h). To control unrelenting muscle spasms, intravenous muscle-relaxant infusion with vecuronium hydrochloride (2–3 mg per h) was started. The patient was nursed in a noise-free environment, with minimal external stimuli. In view of possible prolonged mechanical ventilation, the patient was tracheostomized with 8.5 mm cuffed tracheostomy tube on the 8th day of admission (percutaneous tracheostomy under local anesthesia and intravenous sedation relaxant), under close monitoring in the ICU. Three days after the tracheostomy, the muscle spasms were controlled, and thiopentone and vecuronium infusions were slowly discontinued. Gradual weaning from ventilatory support was started, with daily “sedation holiday.” Midazolam infusion rates were also reduced daily. The patient was finally weaned from the ventilator on the 20th day of admission, and he could maintain oxygen saturation and stable vital parameters well. The patient was then shifted to the medical ward after observation in the ICU for another 48 h, with normal vital parameters and no muscle spasms.


  Discussion Top


Tetanus, though rare in the developed world, is still rampant in the developing world. It was also known to ancient people who recognized the relationship between wounds and fatal muscle spasms. In 1884, Arthur Nicolaier (a German scientist) isolated the strychnine-like toxin of tetanus from free-living, anaerobic soil bacteria.[4] The etiology of the disease was further elucidated in 1884 by Antonio Carle and Giorgio Rattone, two pathologists of the University of Turin, who demonstrated the transmissibility of tetanus for the first time.[5] They produced tetanus in rabbits by injecting pus from a patient with fatal tetanus into their sciatic nerves.

Tetanus is diagnosed by history and clinical signs.[6] The incubation period of tetanus is 3–21 days and the shorter the incubation, the higher the risk of death. There are no laboratory tests for this disease. The first sign of tetanus is spasm. The muscle of the jaw, neck, back, and abdomen may be involved. There are various types of tetanus,[7] including generalized, local, cephalic, and neonatal tetanus. The manifestations of generalized tetanus include pain, stiffness, rigidity, opisthotonus, and laryngeal spasm. The spasms are painful and may be result in respiratory arrest and death. The local tetanus has a low mortality. Cephalic tetanus is an uncommon form that damages the cranial nerves. Neonatal tetanus occurs in the newborn around the 1st week of life, transmitted through the umbilical cord.

Our patient's chief complaint was pain and stiffness in the face. He had spasms in his jaw muscles, leading to inability to open his mouth. Treatment is neutralization of tetanospasmin and care for muscle spasms. Human TIG neutralizes circulating tetanospasmin. The effective dose is 500 IU intramuscular.[8] Penicillin and its analogs are not recommended as they have gamma-2-aminobutyric acid antagonist activity and therefore could potentiate the spasms caused by the tetanus toxin.[9] Metronidazole, 500 mg intravenous four times a day, was chosen for its anaerobic cover. Ceftriaxone 500 mg twice daily was added as a broad-spectrum antibiotic to treat any secondary wound infection with either Staphylococcus or Streptococcus organisms. Timely intubation and tracheostomy for mechanical ventilation were pivotal in saving the patient. The patient was successfully weaned from mechanical ventilation, once muscle spasms were controlled. Our patient did not have serious autonomic disturbances, apart from tachycardia during episodes of muscle spasms, which was controlled with sedative–hypnotic and relaxant infusions. Prolonged muscle-relaxant administration is also deleterious in the long run. At the same time, sustained muscular spasms can lead to muscle damage and sometimes, rhabdomyolysis. Prompt control of spasm, maintaining adequate hydration and urine output, assessment of renal function tests, and avoidance of nephrotoxic agents is advocated.


  Conclusions Top


Tetanus is a life-threatening infection, which is largely preventable. Without timely detection and management, it is fatal. Despite widespread increases in vaccination, tetanus continues to haunt the world of infectious diseases. Tetanus is a clinical diagnosis, and serious cases of tetanus must be managed in an ICU setup. Muscle spasms can be difficult to control, resulting in orthopedic complications and may warrant prolonged sedative-relaxant infusions. Long-term mechanical ventilation may sometimes be required in these patients, with its attendant complications, such as ventilator-associated pneumonia, adult respiratory distress syndrome, sepsis, gastrointestinal stress ulcers, mechanical tube blockade, and tracheomalacia. Early tracheostomy can help in quicker weaning from ventilator and reduce the overall complication rates. Despite several preventive strategies, tetanus remains a serious health problem in the developing world.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Smith JW. Tetanus. In: Wilson G, Miles A, Parker MT, editors. Topley and Wilson's Principles of Bacteriology, Virology, and Immunity. 7th ed., Vol. 3. Baltimore, MD: Williams and Wilkins; 1984. p. 345-68.  Back to cited text no. 1
    
2.
Bleck TP. Tetanus: Pathophysiology, management, and prophylaxis. Dis Mon 1991;37:545-603.  Back to cited text no. 2
    
3.
Mellanby J, Green J. How does tetanus toxin act? Neuroscience 1981;6:281-300.  Back to cited text no. 3
    
4.
Rathod VS, Sinha R, Mukhopadhyay S, Tamboli S, Shegokar V. A case report: Tetanus after piles surgery by a quack doctor in peripheral Maharashtra. Int J Adv Res 2016;4:2138-40.  Back to cited text no. 4
    
5.
Rhee P, Nunley MK, Demetriades D, Velmahos G, Doucet JJ. Tetanus and trauma: A review and recommendations. J Trauma 2005;58:1082-8.  Back to cited text no. 5
    
6.
Smietańska K, Rokosz-Chudziak N, Rastawicki W. Characteristics of clostridium tetani and laboratory diagnosis of tetanus. Med Dosw Mikrobiol 2013;65:285-95.  Back to cited text no. 6
    
7.
Poudel P, Budhathoki S, Manandhar S. Tetanus. Kathmandu Univ Med J (KUMJ) 2009;7:315-22.  Back to cited text no. 7
    
8.
Blake PA, Feldman RA, Buchanan TM, Brooks GF, Bennett JV. Serologic therapy of tetanus in the United States, 1965-1971. JAMA 1976;235:42-4.  Back to cited text no. 8
    
9.
Hassel B. Tetanus: Pathophysiology, treatment, and the possibility of using botulinum toxin against tetanus-induced rigidity and spasms. Toxins (Basel) 2013;5:73-83.  Back to cited text no. 9
    




 

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